Thoughts on medicine in sports

June 11, 2009

10 Reasons Why Sports Physicals Deserve An Appointment

Apparently Elvis was a tighty-whities guy

1. Lack of privacy. Granted, the cattle-call arrangement picture above where kids moved from station to station in an open gym is rare these days. Most mass sports physical set-ups try to incorporate individual exam rooms where providers see athletes one on one. Despite this improvement, any situation that has groups of kids getting standing in line together means that they will be looking at each others forms, asking what you weighed or if you passed, etc. Makes divulging and discussing personal information quite difficult.

2. We don't know each other. In a mass physicals situation provider and athlete do not have any kind of pre-existing relationship. It's hard enough to get teenagers to open up about anything and if they don't know and trust you there is zero chance they'll be comfortable discussing any sort of sensitive topic.

3. Limited time. If 4 doctors have to see 100 kids and take 5 minutes with each one it will take over two hours to finish, and that isn't including the time to register each child, obtain vitals, and check-out. How much can a provider accomplish in 5 minutes? Would any adult accept this when signing up for a physical?

4. Health maintenance issues not addressed. Because of the lack of privacy, trust, and time a young person getting his or her physical in a mass setting will not receive the recommended effective screening or counseling for depression/suicide risk, sexually transmitted disease and pregnancy, and tobacco, alcohol, or drug use. They will not have a discussion about nor receive the HPV or meningococcal vaccinations. They won't be screened for the number one killer of teenagers, motor vehicle accidents.

5. False sense of security. A study done by my colleague Dan Krowchuk here at WFUSM a few years ago showed that a large number of parents intended to use the PPE done at our mass setting as their child's annual check up. By offering such a 'service' we may be doing kids a disservice as they end up missing out on the important screening and interventions mentioned in #4 not to mention individualized care specific to their history and needs.

6. Alot of kids don't have primary care providers. This is actually the most common reason given for why we should still provide mass community PPEs. Many worry that this subgroup of kids otherwise would not see a doctor and miss out on participating in sports. I would argue that mandating in-office check-ups in order to play would actually improve access to the quality healthcare that these young people need and deserve. Somehow each and every child entering kindergarten is able to obtain the required physical and immunizations. Why wouldn't the same thing happen with sports physicals? And even if not every parent was not responsible enough to cooperate, coaches, administrators, other parents would be motivated to identify these kids and help get them where they need to be. Instead we are motivated to slap an inadequate band-aid, the mass PPE, on the problem.

7. Communication is poor. At mass physicals parents often are not present for the interaction with the provider, whether it is because the bus picked all the kids up at school or because they are dropped off in the lobby. If we're lucky a guardian participated in filling out the history form but so often positive responses require further clarification and that can be rather difficult when you only have the input of a 15 year old to go on. If any recommendations are made about medications or further testing for example, how likely is it that even a paper handout makes it out to the car let alone all the way home and into the right hands?

8. Follow-up is challenging. This goes hand in hand with the communication challenges mentioned in #7. If a newly discovered heart murmur needs further work-up with an echocardiogram this is much more likely to actually happen in an office where a system is in place to receive the order, arrange the test, and convey this to a family all before they walk out the door. Yes, when you have assembled cardiologists, orthopedists, and other specialists for a mass screening event a consult may be as simple as a walk down the hall. But then primary care physicians are out of the loop and kept from doing what they do best, coordinate care for the whole patient.

9. Liability. This reason may sound self-serving. The issue, however, is not do I want to somehow avoid responsibility when providing care to an athlete, it's that I want a chance to do my job well if I'm going to take on that liability. And even if the job of performing a PPE is done appropriately, that doesn't mean bad outcomes won't occur. It is still not clear if the PPE saves lives here in the US despite recent evidence presented by the Italians. Deaths will occur and having your name attached to such a case (the first thing most schools say after an athlete passes away is that he or she had a physical) brings legal liability, can damage your reputation, and be emotionally devastating even though there is nothing you could or should have done to prevent it. Compensation for taking on such significant risks seems more than reasonable.

10. Maybe we could be doing something more useful. For every course of action there is one not taken, i.e. an opportunity cost. When I choose to stay up late watching a hockey game I'm much less likely to get up early the next morning to exercise. Medical providers spending time, energy, and money to provide a service are going to be unable to offer alternative services. If mass PPEs are at best less than ideal and at worst a waste of time, maybe their are better places we providers could focus our community service efforts such as volunteering to visit schools and counsel on STD and pregnancy prevention or take a few extra hardship cases into our practice.